Pretreatment minimal staging for non-small cell lung cancer: an updated consensus report

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LUNG

CANCER

ELSEVIER

Lung Cancer 11 Suppl. 3 (1994) Sl-S4

Pretreatment minimal staging for non-small cell

lung cancer: an updated consensus report *

P. Goldstraw*a, P. Rocmansb, D. BallC, N. Barthelemyd,

J. Bonnere, &I. Carette’, N. Choig, B. Emamih, D. Grunenwald’,

M. Hazuka’, D. Ihde’, J. Jassem’, G. Khom, T. Le Chevalieir”,

M. Monteau’, G. StormeP, S. Wagenaarq

aDepartment of Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London S W3 6NP, UK, bHospital Erasme, Brussels, Belgium

‘Peter MacCallum Cancer Institute, Melbourne. Australia ?entre Hospital, Vnivversity de Liege, Liege, Belgium

‘Mayo, Clinic, Rochester, MN, USA ‘Hopita Tenon, Paris, France

gMassachusetts General Hospital, Boston, MA, USA h Washington University Medical Center, St. Louis, MO. USA

‘Serv. de chirurgie thoracique, Paris, France iUniversity of Michigan, Ann Arbor, MI. USA kNational Navy Medical Center. Bethesda, MD, USA

‘Medical Academy, Gdansk. Poland

“‘Academy Ziekenhuis Rotterdam, Rotterdam, The Netherlands “Initut Gustave-Roussy, Villejuif; France

‘Polyclinique de Courlancy. Reims, France PA-2 Vrde Vniversiteit Brussell, Jeite, Belgium a University of Limburg, Maastricht. The Netherlands

In making its recommendations the Group set out a number of objectives.

(a)

Any staging protocol should be simple and widely applicable, without being

limited to the lowest common demoninator.

(b)

The staging protocol should be sequential and logical, avoiding unnecessary

tests which might prove expensive and invasive.

(c)

The staging protocol proceeds to identify patients suitable for treatment with

curative intent since there is no purpose to staging for palliative therapy.

(d)

The staging protocol should be applicable to good clinical practice with all

* Pretreatment minimal staging for non-small cell lung cancers: a consensus report. Goldstraw P et al. Lung Cancer 1991; 7: 7-9.

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s2 P. Goldstraw et al. /Lung Cancer II Suppl. 3 (1994) SI-S4

forms of therapy. There would be no restriction on institutional preference for

additional investigations, nor additional requirements for trial purposes.

In making its recommendations the group made the following assumptions.

(a)

Any staging protocol would be TNM based (UICC or AJC equivalent)

(b)

The staging protocol covered only non-small cell lung cancer (NSCLC)

(c)

No recommendations were made regarding which groups might be appropriate

for different forms of therapy. This was deemed to be the domain of individual

clinicians and their institutions.

(d)

We assumed that the diagnosis already had been established.

(e)

Patient suitability should be separately assessed, and we assumed that each pa-

tient was lit for all forms of therapy.

The staging protocol involves 3 steps, as outlined in the following tables.

Step I

Investigation Patient group Confirmatory tests

Clinical history (to include) Clinical examination Chest radiographs

Blood tests

Weight loss and performance status PA Lateral Hb AIk Phos Transaminase LDH All patients All patients All patients All patients As appropriate As appropriate Aspiration of effusion (considered positive if cytology malignant) As for high risk patients in Step II

If still thought suitable for curative therapy proceed to Step II.

Step II

Investigation Patient group Confirmatory tests

Bronchoscopy All patients with central tumours or those in whom central extension is suspected

The features of proximal, extrin- sic compression are unreliable and require further evaluation of the mediastinum by CT and/or mediastinal exploration Bone scan High risk groupa Skeletal X-rays f CT/MRI of

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P. Goldrtraw et al. /Lung Cancer II Suppl. 3 (1994) SI-S4 s3 CT chest and upper abdomen All patients if available Dubious findings confirmed (not (to lower pole of kidneys, necessarily histological) with i.v. contrast enhancement

of mediastinal vessels) Liver ultrasound

Brain assessment by CT or MRI

High risk groupa if CT of abdomen not available

Advisable in high risk groupa

??Unexplained anaemia (Hb < II G%)

??Unexplained weight loss (>8 lb (3 kg) in 6112) ??Abnormal alk phosphatase, or transaminase ??Where any clinical suspicion of metastatic disease ??Patients with stage III disease

aHigh risk patients are those having non-specific features identified by Hooper et al. (1987) Am Rev Respr Dis 118: 279.

If still thought suitable for curative treatment proceed to Step III.

Step III

Investigation Patient group

(a) Bronchoscopy if not previously undertaken All patients

(b) Thoracoscopy or video assisted If pleural effusion present, thoracoscopy cytology negative but clinical suspicion remains (c) Mediastinal exploration

9 It is recommended that this is performed pre-operatively by

??Transcarinal aspiration ??Cervical mediastinoscopy

Patients in whom CT suggests mediastinal inva- sion or if CT shows nodes> I.0 ems

??Additional evaluation of the subaortic

fossa by left anterior mediastinotomy

The above groups with tumours of the left upper lobe and left main bronchus

??This must be performed intra-

operatively

All patients - including those whose mediastinum has been assessed preoperatively

??Palpation insufficient

??Careful and extensive mediastinal

dissection

??Separate labeling as per Naruke or

ATS of excised nodes for subsequent histological examination (only Nl nodes on resection specimen)

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s4 P. Goldrtraw et al. /Lung Cancer II Suppl. 3 (1994) SI-S4